Provider Demographics
NPI:1225185739
Name:MICHAEL J. O'CONNELL D.O. INC
Entity Type:Organization
Organization Name:MICHAEL J. O'CONNELL D.O. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-287-7205
Mailing Address - Street 1:17960 CLEVELAND ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635
Mailing Address - Country:US
Mailing Address - Phone:574-287-7205
Mailing Address - Fax:574-232-5045
Practice Address - Street 1:17960 CLEVELAND ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-287-7205
Practice Address - Fax:574-232-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000569A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE23984Medicare UPIN
IN737750Medicare PIN